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BACKGROUND: Evidence-based preventive care in the USA is underutilized, diminishing population health and worsening health disparities. We developed Project ACTIVE, a program to improve adherence with preventive care goals through personalized and patient-centered care. OBJECTIVE: To determine whether Project ACTIVE improved utilization of preventive care and/or estimated life expectancy compared to usual care. Design: Single-site randomized controlled trial. PARTICIPANTS: Cluster-randomized 140 English or Spanish speaking adult patients in primary care with at least one of twelve unfulfilled preventive care goals based on USPSTF grade A and B recommendations. INTERVENTION: Project ACTIVE employs a validated mathematical model to predict and rank individualized estimates of health benefit that would arise from improved adherence to different preventive care guidelines. Clinical staff engaged the participant in a shared medical decision-making (SMD) process to identify highest priority unfulfilled clinical goals, and health coaching staff engaged the participant to develop and monitor action steps to reach those goals. MAIN MEASURES: Change in number of unfulfilled preventive care goals from USPSTF grade A and B recommendations and change in overall gain in estimated life expectancy. KEY RESULTS: In an intent-to-treat analysis, Project ACTIVE increased the average number of fulfilled preventive care goals out of 12 by 0.68 in the intervention arm compared with 0.15 in the control arm (mean difference [95% CI] 0.53 [0.19–0.86]), yielding a gain in estimated life expectancy of 8.8 months (3.8, 14.2). In a per-protocol analysis, Project ACTIVE increased fulfilled preventive care goals by 0.80 in the intervention arm compared with 0.16 in the control arm (mean difference [95% CI], 0.65 [0.25–1.04]), yielding a gain in estimated life expectancy of 13.7 months (6.2, 21.2). Among the 12 preventive care goals, more improvement occurred for alcohol use, hypertension, hyperlipidemia, depression, and smoking. CONCLUSIONS: Project ACTIVE improved unfulfilled preventive care goals and improved estimated life expectancy. CLINICAL TRIAL REGISTRATION NUMBER: NCT04211883 SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06359-z.

Background The Affordable Care Act and the introduction of accountable care organizations (ACOs) have increased the incentives for patients and providers to engage in preventive care, for example, through quality metrics linked to disease prevention. However, little is known about how ACOs deliver preventive care services. Objective To understand how Medicare ACOs provide preventive care services to their attributed patients. Design Mixed-methods study using survey data reporting Medicare ACO capabilities in patient care management and interviews with high-performing ACOs. Participants ACO executives completed survey data on 283 Medicare ACOs. These data were supplemented with 39 interviews conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff. Main Measures Survey measures included ACO performance, organizational characteristics, collaboration experience, and capabilities in care management and quality improvement. Telephone interviews followed a semi-structured interview guide and explored the mechanisms used, and motivations of, ACOs to deliver preventive care services. Key Results Medicare ACOs that reported being comprehensively engaged in the planning and management of patient care - including conducting reminders for preventive care services - had more beneficiaries and had a history of collaboration experience, but were not more likely to receive shared savings or achieve high-quality scores compared to other surveyed ACOs. Interviews revealed that offering annual wellness visits and having a system-wide approach to closing preventive care gaps are key mechanisms used by high-performing ACOs to address patients’ preventive care needs. Few programs or initiatives were identified that specifically target clinically complex patients. Aside from meeting patient needs, motivations for ACOs included increasing patient attribution and meeting performance targets. Conclusions ACOs are increasingly motivated to deliver preventive care services. Understanding the mechanisms and motivations used by high-performing ACOs may help both providers and payers to increase the use of preventive care.

Provider and patient reminders can be effective in increasing rates of preventive screenings and vaccinations. However, the effect of patient-directed electronic reminders is understudied.To determine whether providing reminders directly to patients via an electronic Personal Health Record (PHR) improved adherence to care recommendations.We conducted a cluster randomized trial without blinding from 2005 to 2007 at 11 primary care practices in the Partners HealthCare system.A total of 21,533 patients with access to a PHR were invited to the study, and 3,979 (18.5%) consented to enroll.Patients in the intervention arm received health maintenance (HM) reminders via a secure PHR "eJournal," which allowed them to review and update HM and family history information. Patients in the active control arm received access to an eJournal that allowed them to input and review information related to medications, allergies and diabetes management.The primary outcome measure was adherence to guideline-based care recommendations.Intention-to-treat analysis showed that patients in the intervention arm were significantly more likely to receive mammography (48.6% vs 29.5%, p = 0.006) and influenza vaccinations (22.0% vs 14.0%, p = 0.018). No significant improvement was observed in rates of other screenings. Although Pap smear completion rates were higher in the intervention arm (41.0% vs 10.4%, p 0.001), this finding was no longer significant after excluding women's health clinics. Additional on-treatment analysis showed significant increases in mammography (p = 0.019) and influenza vaccination (p = 0.015) for intervention arm patients who opened an eJournal compared to control arm patients, but no differences for any measure among patients who did not open an eJournal.Providing patients with HM reminders via a PHR may be effective in improving some elements of preventive care.

The factors that affect the implementation of preventive care for contrast-induced acute kidney injury (CIAKI) are unknown.To assess patient and provider factors associated with the use of preventive care for CIAKI.Prospective cohort study.Patients with kidney disease undergoing procedures with intravascular iodinated radiocontrast.We recorded the use of preventive care defined as the administration of: (1) pre- and post-procedure isotonic intravenous (IV) fluid, (2) N-acetylcysteine, and (3) iso-osmolal radiocontrast. We surveyed patients' providers to assess their knowledge, experience, and training on CIAKI and used multiple logistic regression to assess the independent associations of patient and provider factors with the use of these preventive interventions.We enrolled 660 patients and 87 providers. Patient factors associated with use of IV fluid and N-acetylcysteine were higher baseline serum creatinine (OR 1.5 and 5.0, p0.05) and inpatient status (OR 3.0 and 6.3, p0.05), while higher baseline serum creatinine was associated with the use of iso-osmolal contrast (OR = 13.4, p0.01). The primary provider characteristics associated with the use of IV fluid and N-acetylcysteine were a greater degree of prior training on CIAKI (OR 1.9 and 2.8, p0.05) and higher number of prior patients with CIAKI (OR 2.7 and 2.6, p0.05).Patient baseline kidney function and provider training and experience with CIAKI are independently associated with the use of preventive care. Efforts to increase and intensify the training providers receive on CIAKI may help decrease the incidence of this costly iatrogenic condition.

The implications of measuring and rewarding performance for patients with multiple chronic conditions have not been explored empirically.To examine whether the number of chronic conditions was associated with patient's receipt of recommended preventive care.We evaluated the association between the likelihood of receiving recommended preventive care and the number of chronic conditions in the diabetic population by analyzing the 2003 Medical Expenditure Panel Survey using logistic regression. Demographic characteristics and the number of chronic conditions were compared using chi(2) tests.Hemoglobin A1C test and diabetic eye exam.In 2003, approximately 14.2 million non-institutionalized Americans had diabetes and 23% of them had five or more chronic conditions besides diabetes. Those patients were 67% (p0.05) and 50% (p0.001) more likely to receive hemoglobin A1C test and eye exams compared with diabetic patients with no additional chronic conditions. After adjusting for the number of office-based physician visits, a larger number of chronic conditions did not significantly affect the likelihood of receiving recommended care. Diabetic patients with more chronic conditions had more frequent office-based physician visits (p0.0001), and patients with 11 or more annual office-based physician visits were 43% (p0.05) and 40% (p0.01) more likely to receive hemoglobin A1C test and eye exam, respectively, compared with diabetic patients who had less than two office-based physician visits.Diabetic patients with more chronic conditions may receive better quality of preventive care, partly due to their higher number of office-based physician visits.

As cancer patients transition from treatment to survivorship, the responsibility of primary care providers (PCPs) versus oncology specialists is unclear.To explore (1) physician types (PCPs versus oncology specialists) survivors visit during survivorship year 1, (2) preventive care received, (3) how preventive care receipt relates to physician types visited, and (4) trends in physician types visited and preventive care received over time.Retrospective cross-sectional study of 5 cohorts of cancer survivors in survivorship year 1.Twenty thousand sixty-eight survivors diagnosed with stage 1-3 colorectal cancer between 1997 and 2001.Using the SEER-Medicare database, we assessed the mean number of visits to different physician types, the percentage of survivors receiving preventive services, how receipt of preventive services related to physician types visited, and trends over time in physician visits and preventive care.There was a trend over time of increased visits to all physician types, which was statistically significant for oncology specialists and other physicians (p.001) but not PCPs. The percentage of survivors receiving preventive services remained relatively stable across the 5 cohorts, except for an increase in bone densitometry (p.05). Survivors who visited both a PCP and oncology specialist were most likely to receive each preventive care service (p.05).Oncology specialist follow-up in survivorship year 1 is intensifying over time. Survivors not being followed-up by both PCPs and oncology specialists were less likely to receive preventive care. Clarifying the roles of PCPs and oncology specialists during follow-up can improve the quality of care for survivors.

Quality of cardiovascular disease (CVD) preventive care is suboptimal. Recent data correlated increasing years in practice for physicians with lower-quality health care.The purpose of this study was to assess physician awareness/adherence to national blood pressure, cholesterol, and CVD prevention guidelines for women according to physician/practice characteristics.Standardized online survey and experimental case studies were administered to 500 randomly selected U.S. physicians. Multivariable regression models tested physician age, gender, specialty, and practice type as independent predictors of guideline awareness/adherence.Compared with older physicians (50+ years), younger physicians (50 years) reported a lower level of awareness of cholesterol guidelines (P=.04) and lower incorporation of women's guidelines (P=.02). Yet, older physicians were less likely to recommend weight management for high-risk cases (P=.03) and less confident in helping patients manage weight (P=.045) than younger physicians. Older physicians were also less likely to identify a low-density lipoprotein100 mg/dL as optimal versus younger physicians (P=.01), as were solo versus nonsolo practitioners (P=.02). Solo practitioners were less aware of cholesterol guidelines (P=.04) and were more likely to prescribe aspirin for low-risk female patients than nonsolo practitioners (P.01). Solo practitioners rated their clinical judgment as more effective than guidelines in improving patient health outcomes (P.01) and more frequently rated the patient as the greatest barrier to CVD prevention versus nonsolo practitioners (P.01).Though guideline awareness is high, efforts to promote their utilization are needed and may improve quality outcomes. Targeted education and support for CVD prevention may be helpful to older and solo physicians.

In recent years, there has been a growing interest in reducing the overuse of healthcare services. However, little is known about how patients conceptualize the benefits and harms of overused screening tests or how patients make decisions regarding these tests.To determine how patients think about the harms and benefits of overused screening tests and how they consider these and other factors when making decisions.Semi-structured, qualitative interviews.The study comprised 50 patients, ages 50-84, who had previously received or not received any of four overused screening services: 1) prostate cancer screening (men ages 50-69), 2) colon cancer screening (men and women ages 76-85), 3) osteoporosis screening (low-risk women ages 50-64), or 4) cardiovascular disease screening (low-risk men and women ages 50-85).We conducted a thematic analysis, using a hybrid inductive-deductive approach. Two independent coders analyzed interview transcriptions to identify themes and exemplifying quotes.Many patients could not name a harm of screening. When they did name harms, patients often focused on only the harms of the screening test itself and rarely mentioned harms further along the screening cascade (e.g., from follow-up testing and treatment). In contrast, patients could easily name benefits of screening, although many seemed to misunderstand or overestimate the magnitude of the benefits. Furthermore, patients described many additional factors they considered when making screening decisions, including their clinicians' recommendations, their age, family or friends' experiences with disease, and insurance coverage.This study highlights the need to help adults recognize and understand the benefits and harms of screening and make appropriate decisions about overused screening tests.

To determine the feasibility of cervical cancer screening in an urgent care clinic.Prospective randomized trial.Public teaching hospital.Women presenting to the urgent care clinic whose evaluation necessitated a pelvic examination were eligible for participation. Women who had a hysterectomy, had a documented Pap test at our institution in the past year, did not speak English or Spanish, or had significant vaginal bleeding were excluded. Women presenting to the gynecology clinic for a scheduled Pap test were used as a comparison group for rates of follow-up, Pap smear adequacy, and Pap smear abnormalities.Women randomized to the intervention group had a Pap test performed as part of their pelvic examination, while women in the usual care group were encouraged to schedule an appointment in the gynecology clinic at a later date. The women in the two groups completed identical questionnaires regarding cervical cancer risk factors and demographic information.Ninety-four (84.7%) of 111 women in the intervention group received a Pap test, as compared with 25 (29%) of 86 in the usual care group (P.01). However, only 5 (24%) of 21 women with abnormal Pap smears in the intervention group received follow-up compared with 6 (60%) of 10 women seen during the same time period in the gynecology clinic for self-referred, routine annual examinations (P =.11). Pap smears obtained in the urgent care clinic were similar to those in the gynecology clinic with regard to abnormality rate (22.3% vs 20%; P =.75, respectively) and specimen adequacy (67% vs 72%; P =.54, respectively).Urgent care clinic visits can be used as opportunities to perform Pap test screening in women who are unlikely to adhere to cervical cancer screening recommendations. However, to accrue the full potential benefit from this intervention, an improved process to ensure patient follow-up must be developed.

BACKGROUND Latinos are the largest minority group in the United States and experience persistent disparities in access to and quality of health care. OBJECTIVES (1) To determine the relationship between nativity/immigration status and self-reported quality of care and preventive care. (2) To assess the impact of a usual source of health care on receipt of preventive care among Latinos. DESIGN Using cross-sectional data from the 2007 Pew Hispanic Center/Robert Wood Johnson Foundation Hispanic Healthcare Survey, a nationally representative telephone survey of 4,013 Latino adults, we compared US-born Latinos with foreign-born Latino citizens, foreign-born Latino permanent residents and undocumented Latinos. We estimated odds ratios using separate multivariate ordered logistic models for five outcomes: blood pressure checked in the past 2 years, cholesterol checked in the past 5 years, perceived quality of medical care in the past year, perceived receipt of no health/health-care information from a doctor in the past year, and language concordance. RESULTS Undocumented Latinos had the lowest percentages of insurance coverage (37% vs 77% US-born, P

The objective of the study was to measure the change in physicians' attitudes toward preventive care guidelines over a 2-year period. The study was conducted at a Southern California managed care medical group that was experiencing intense price competition. We analyzed individualized survey responses of 62 HMO primary care physicians over the study period. We found that physicians increasingly believed that clinical guidelines were being used for cost containment (first survey 71% vs second survey 92%, p < .005) and less for quality improvement (first survey 85% vs second survey 67%, p < .008) over time. These findings may create a barrier to physicians' adoption of practice guidelines.

The objective of this study was to assess reasons for physicians' noncompliance with computer-generated preventive care reminders. In an academic general internal medicine practice, a survey of physicians' reasons for noncompliance found that 55% of reminders were not complied with. Reasons included "not applicable" in 22.6% (test done elsewhere, patient too ill, no uterus), "next visit" in 22.5% (physician too busy, patient too ill), and "patient refuses" in 9.9% (test not necessary or too costly, patient too busy or fears result). We conclude that although noncompliance with reminders is sometimes appropriate, making time for prevention and patient education may augment preventive care.

To identify preventive care measures that are appropriate for and specific to patients with chronic liver disease and to provide recommendations and information that can be shared with patients.A review of the literature was undertaken using MEDLINE from 1970 to present. Priority was given to randomized controlled studies, but case reports, case-control studies, and reviews were included.Evidence for the avoidance of alcohol and other toxic substances, immunizations, and dietary modifications for chronic liver disease is summarized. In addition, measures that are effective in the mitigation of the complications of cirrhosis are reviewed.Preventive care can play an important role in patients with chronic liver diseases. Based on the existing data, the preventive strategies of alcohol avoidance, hepatitis vaccination, avoidance of NSAIDs nonsteroidal anti-inflammatory drugs, iron supplementation when appropriate, and a low-fat diet are prudent in patients with chronic liver disease. Once cirrhosis develops, screening for hepatocellular cancer with alpha-fetoprotein testing and ultrasound, and screening for varices by endoscopy are justified.

To examine whether health insurance, a regular place of care, and optimal primary care are independently associated with receiving preventive care services.A cross-sectional telephone survey.Population based.Probability sample of 3,846 English-speaking and Spanish-speaking women between the ages of 18 and 64 in urban California.Women were asked about their demographic characteristics, financial status, health insurance status, need for ongoing care, regular place of care, and receipt of blood pressure screening, clinical breast examinations, mammograms, and Pap smears. Women who reported a regular place of care were asked about four components of primary care: availability, continuity, comprehensiveness, and communication.In multivariate analyses that controlled for differences in demographics, financial status, and need for ongoing care, having a regular place of care was the most important factor associated with receiving preventive care services (p.0001). Having health insurance (p.001) and receiving optimal primary care from the regular place of care (p.01) further significantly increased the likelihood of receiving preventive care services.A regular source of care is the single most important factor associated with the receipt of preventive services, but optimal primary care from a regular place increases the likelihood that women will receive preventive care.

To measure primary care physicians' familiarity with, attitudes toward, and confidence in preventive care practice guidelines for the elderly and to determine whether their attitudes are associated with implementation of guidelines into clinical practice.A self-administered survey of physicians employed by a health maintenance organization (HMO) and of patients cared for by those physicians. Medical records were also reviewed to assess compliance with practice guidelines.An HMO in Southern California.Forty-eight primary care physicians completed the survey (100% response rate). The medical records of 3,249 randomly selected elderly patients (65 to 75 years old) were studied. Of these patients, 2,799 completed a preventive care survey (response rate 86.1%).Most HMO primary care physicians agreed or strongly agreed that guidelines will improve quality of medical care (88%) and that guidelines have caused them to change their care of patients (73%). Although the physicians' general attitudes about guidelines did not often correlate with their use of preventive care guidelines, the physicians who stated that practice guidelines had changed their practices were more likely to offer their patients clinical breast examinations (75.9% vs 67.2%, p = 0.04) and to counsel their patients to exercise (70% vs 58%, p = 0.01) than were the physicians who did not. There was a significant association between physicians' support for and adoption of specific practice guidelines regarding mammography (r = 0.34, p = 0.02) and immunizations against influenza (r = 0.42, p0.005), pneumococcal pneumonia (r = 0.47, p0.001), and tetanus (r = 0.31, p = 0.03).Physicians employed by an HMO were familiar with and hopeful about the role of guidelines for improving patient care. Physicians' attitudes toward specific preventive care guidelines and admission that guidelines had caused them to change their practice did at times, but not always, correlate with their implementation of guidelines into clinical practice.